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Dorsal Ganglion

,
more than a simple pathology

Jérôme Garret
Clinique du Parc LYON

Dorsal Wrist Ganglion,

1- Cosmetic or functional?
2- Enigmatic physiopathology!

3- Which treatment?

Results medical treatment

Reccurence

50%

Meta analyse Linden JHS 2015
512 Ao / 809 Open / 918 Med
Complications:
- 14% Open
- 4% Ao
- 0% Med
Reccurences
- Open 21%
- Ao 6%
- Med 59%

Gallego et Mathoulin arthroscopy 2010
min 2 yo FU – 114 pts
Recurrence 12 %
Kim et coll Arthroscopy 2013
115 pts
11% Recurrence
23% persistant pain

Reccurence

12 to 15 % 

SFA 2015 Multicentric Retrospective study
331 pts – Minimun 2 yo FU
15% Recurrence
8% persistant pain

Improve our knowledge
of DWG anatomy

Background
Ganglion of the wrist : proposals for topographical systematization and
natural history.” Kulhmann JN & al . Rev Chir Orthop Réparatrice Appar

Mot 2003; 89: 310-9

.

• Mucoïd degeneration
• Hyaluronic acid
• Synovial Liquid
Dorsal Wrist Ganglion,
more than a simple pathology
It’s not a simple « arthro synovial cyst »

Prospective study B Bordet & J Garret LYON
Materials & Methods
• 42 patients MRI / 14 @ (10f/4h-26 ans)
• Dorsal ganglion cyst
• MRI 3D 1,5 T 0,7mm DP FS et T1 3D
IV gadolinium

Results
• RMI: same origin for all the cyst = DCSS
Anatomical Description of the Dorsal Capsulo- Scapholunate Septum (DCSS).
Arthroscopic Staging of Scapholunate Instability after DCSS Sectioning
Luc Van Overstraeten & Christophe Mathoulin & co JWS 2013

• Gadolinium enhancement wall cyst
• @: No rupture of scapho lunate ligament
Scapho lunate hypermobility = hyperlaxe pts
(6 llc EWAS)

Anatomy
Scapho Lunate
Ligament
SL

Dorsal Radio Carpal
Ligament
DRC
Dorsal Inter Carpal
Ligament
DIC

3D MRI DP FS DRC
MPR coronal oblique

LRCD

DIC

DIC

Dorsal portion SL

SL dorsal portion

3D MRI DP FS sagittal view

DIC
LSL
DRC

3D MRI DP FS sagittal view

Mediocarpal joint

Radiocarpal joint

3D MRI DP FS sagittal view

DCSS

3D MRI DP FS sagittal view

DCSS

Arthro TDM
Arthrography

DCSS

Ultrasound
Radio carpal

DCSS

Medio carpal

Ganglion
cyst
Case 1 3D MRI DPFS MPR

Cyst’s Origin = DCSS

Ganglion cyst ‘s origin

Cyst ‘s origin - pedicle – Cyst

Volumic reconstruction

Ganglion
CASE 2cyst

Cyst’s origin = DCSS

Ganglion cyst ‘s origin

3D MRI T1 gadolinium iv
SAGITTAL MPR

Gadolinium Enhancement
of the cyst wall

We suggest a new
physiopathology
by analogy with the Anterior
Cruciate Ligament ACL

ACL = Intra articular & Extra synovial

DCSS = Intra articular & Extra synovial

Chronic ACL tears
1- Tear of the synovial membrane
extracellular matrix

structural changes in the

2- IL & TNF alpha of synovial fluid fix HA of the matrix.
3- Mesenchymal cells of the ligament secrete abnormal quantity of
proteoglycans
aggregates & HA cyst
« Post injury changes in the properties of mesenchymal
stem cells
derived from human anterior cruciate ligaments. »
Nohmi S & al Int Orthop. 2012 Jul.
Mesenchymal stem cells derived from synovium, meniscus,
anterior cruciate ligament, and articular chondrocytes
share similar gene expression profiles.
Segawa Y and al J Orthop Res 2009

How does this apply to DCSS model?

1- DCSS « key structure »
of wrist biomechanics

How does this apply to DCSS model?

2- Trauma – Overuse – Hyperlaxity

Rupture of the synovial membrane

How does this apply to DCSS model?
3-DCSS loss of waterproofing
Deregulation of the mesenchym cells
Abnormal secretation HA

What about the clinical
presentation ?

Prospective Study SFA 2015
64 pts January 2015 – June 2015
86% Unsightly DWG
Permanent pain 22%
Pain in extension 64%
Pain in Flexion 46%

14% Occult ganglion cyst
Gustavo Montavani suggest
a new pathologic entity

« PHYWS »
Pain

HYpermobility

Wrist

Syndrom

Courtesy G Montovani

PHYWS
MRI 3D Injection IV gadolinium +++

Static SL instability

Dynamic SL instability

According G. Montovani

PHYMS »
=
Pre dynamic SL instability
«

Hand Clin 2011 Arthroscopic Dorsal Capsulo Ligamentous Repair ADCLR
in chronic scapholunate ligament tears. C. Mathoulin & al
ADCLR

What about the
origin of the pain?

1 – Inflammatory
2- Dorsal Capsule Impingment
3-Interosseus posterior
Compression Nerve
4- SL Pre instability
(Montovani hypothesis)

?

Prospective Multicentric study SFA 2015
64 pts DWG @ January 2015 & June 2015
EWAS classification SL instability
3B : 4 % 3C : 2 %
2C : 11 %
2B : 5 %
2A : 7 %

Stade 1 : 71 %

Classic @ treatment
of dorsal ganglion cyst
Capsulectomy
Mid carpal
Radio carpal

Mid carpal capsulectomy

Mid carpal & radio carpal capsulectomy

What are we doing?
Can we create iatrogenic
ligaments injuries?

Cadaveric study SFA 2015 F. Loisel MD
Mid carpal capsulectomy

Mid & Radio carpal capsulectomy

Example MC & RC capsulectomy

DRC intact
DIC intact
DCSS intact

Mid Carpal capsulectomy
• DIC type B +++ (Viegas)

• DIC type C (Viegas)

• RC capsulectomy: risk lesion DCSS
• We must know the anatomy DIC & DRC & DCSS
• We must respect « what you see & what you feel »

My guide line for
DWG treatment

First : Medical treatment
Plast Surg (Oakv). 2015 Spring;23(1):51-3.
Long-term outcomes and patient satisfaction following wrist ganglion
aspiration.
Head L1, Allen M2, Boyd KU2.

• 52.4% of ganglions recurred
95% of patients were satisfied with their
treatment and would proceed again given the
option
• improvement in pain, function, range of motion
and appearance; improvement in symptoms
was independent of recurrence

Arthroscopic Treatment
in case of failure of the medical treatment
Unsightly DWG :

Occult Ganglion Cyst:

MC & RC capculectomy

ADCLR

No more place for open surgery for the DWG
For the volar ganglion cyst = No opinion

Thank you for your attention

jeromegarret@free.fr